Nursing 267 Exam 1 review

Role of Professional Nurse

promote health, prevent illness, treat human response, advocate for patients

Nursing Values

Respect, unity, diversity, integrity, excellence

Health

Point between wellness and illness, can be high or low level of health

"Healthy People"

government initiative to focus on health promotion and risk reduction strategies

4 main goals of nursing

promote health, prevent illness, treat human responses, advocate for patients and families

Nursing Process

Assessment, Diagnosis, Setting goals and outcomes, Planning, Intervention, Evaluation

Diagnostic Reasoning

nurses use critical thinking to cluster the assessment information to draw inferences and propose diagnoses

Types of Assessment

emergency, comprehensive, focused

Subjective Data

based on patient experiences and perceptions

Objective Data

measurable, usually collected as part of physical assessment

Organizing Framework for Assessment

functional, head-to-toe, body systems

Evidence-based nursing

relies on research findings and high-grade scientific reports

Therapeutic Communication Techniques

active listening, restatement, reflection, elaboration, silence, focusing, clarification, summarizing

Non-therapeutic Responses

false reassurance, sympathy, unwanted advice, leading or biased questions, changes of subject, distractions, too may technical terms, talking too much

Interview Process

Preinteraction phase, beginning phase, working phase, closing phase

Intercultural Communication

sensitivity and knowledge of specific cultures, languages, health beliefs, gender issues

Secondary Data

Obtained from chart or family

Emergency Assessment

Client is unstable

Focused Assessment

Narrower, and specific to a presenting problem

Comprehensive Assessment

Covers all body systems for screening and health promotions

Comprehensive Health History

reason for seeking care, history of present illness, past health history, current medications and indications, family history, functional health assessment, growth an development, Review of Systems

History of Present Illness

Assessment of location, intensity, duration, description, aggravating and alleviating factors, functional impairment, pain goal

Complete family history

use a genogram to illustrate family patterns

Functional Health Assessment

health perception, nutrition, elimination, activity, sleep, cognition, self-perception, roles, sexuality, coping, values

Assessing ADLs

feeding, bathing, toileting, dressing, grooming, mobility, home maintenance, shopping, cooking

Complete Review of Systems

Nutrition/hydration, hair/skin/nails, head/neck, eyes/ears, hear, peripheral vascular, breasts, abdominal, musculoskeletal. neurological, genitalia, rectum, endocrine/hematological

Hand Hygiene

Most important action to prevent nosocominal infection

Latex Allergies

more common in nurses and patients than in general public

Gloves

worn whenever one may come in contact with bodily secretions

Techniques for Physical Assessment

Inspection, Percussion, Palpation, Ausculation

Inspection

relies on vision, smell

Light Palpation

Overall Impression

Deep Palpation

Assess pain, masses, tumors

Pecussion

Based on tone, intensity, pitch, quality, duration, location

Stethoscope Used

used to examine heart, lungs, abdomen

Advanced Technique equipment

ophthalmologist, visual acuity chart, otoscope, tuning fork, reflex hammer, vaginal speculum, goniometer, skinfold calipers

Patient Record

legal document, communication for care and planning, quality assurance, financial reimbursement, education, research

Electronic Patient Record

Enhances communication and declines risk as it is timely date and better hand writing

Documentation description

Accurate, objective, organized, concise, complete, legible

Health Care Confidentiality

HIPAA

Formats for Nursing Notes

SOAP, PIE, DAR, CBE, Narrative

Handoffs

Transfer patient care

SBAR

mental model for organizing communication

General Survey

patient encounter, progresses through history and physical examination, continues with subsequent interaction

Includes overall appearance, hygiene and dress, skin color, body structure and development, behavior, facial expression, level of consciousness, speech, mobility, posture, range of motion, gait

Indications for Rapid Response

extreme anxiety, acute distress, pallor, cyanosis, changes in mental status, changes in vital signs

Anthropometric

height and weight

Vital signs

reflect patient status, cardiopulmoary function, overall function of body

Temperature

oral, axillary, tympanic, temporal artery, rectal

Pulse

rate, rhythm, amplitude, elasticity

Respiratory Rate Affected by:

smoking, positioning, medication, neurological injury, hemoglobin levels

Respirations

rate, rhythm, depth, use of accessory muscles

Oxygen Saturation

less than 92% indicates inadequate oxygenation to tissues

BP Affected by:

age, gender, ethnicity, weight, circadian cycle, position, exercise, emotions, stress, medications, smoking

Brachial artery

used for BP

Width of BP Cuff

equal 40% of length of patients upper arm, bladder should equal 80% of circumference of arm

Postural Vital Signs

taken sitting, lying and standing. Orthostatic changes may indicate intravascular volume depletion

Vital Signs Monitor

Used in hospital settings

Doppler Transducer

Used if pulse and BP are difficult to auscultate or palpate

Vital Signs Change in Older Adults

because of physiological changes

Pain Causes

stimuli transmitted via peripheral nervous system to CNS where it is processed

Pain Location

musculoskeletal or neuropathic depending on source of stimuli

Verbal Descriptors

burning, tingling, numbness and tingling can suggest nueropathic pain

Decrease of 2 points on Numeric Pain Intensity

Considered clinically significant

Assessing pain

use scales designed for specific population to which the patient belongs

Chronic pain

Patient needs more than one intensity rating, multidimensional scale like BPI

Avoidance of Labeling and stigmatization of pain

important for patients dependent on meds to control theirs

Reassessing Pain

Provides a mean of determining the efficacy of administered pain meds

Skin Assessment

Overall health, hydration, nutritional status

Skin COlor

variations result from amounts and proportions of pheomelanin and eumelanin produced by melanocytes

Skin changes during pregnancy

melasma, linea nigra, increased sebaceous and cutaneous gland function, hair loss

Aging SKin

loss of elastin, collagen, subcutaneous fat causes decreased resilience, sagging, wrinkling, increased fragility

ABCDEs of melanoma

Asymmetry, Border irregularity, color, diameter more than 6mm, Evolution of lesion over time

Common integumentary symptoms

pruritus, rash, lesions, wounds

Coning and Cupping

self treatments performed by cultural home remedies

Inspection of skin

general color, texture, moisture, turgor, temp, palpation of rashes, lesions, wounds

Assessing a lesion

configuration, pattern, morphology, size, distribution, exact location

Assessing wound

location, size, color, texture, drainage, margin, surrounding skin, healing status

Burn depth

superficial, superficial-dermal, dermal, full thickness

Unexpected SKin findings

infection, inflammation, infestation, growths, tumors, trauma, ulcers

Common nursing diagnoses for skin

impaired skin integrity, impaired tissue integrity, pain, risk for infection

thorax reference lines

midsternal, midclavicular, anterior axillary, midasillary posterior axillary, vetebral, scapular

On anterior chest, apex of lung

2 to 4cm above inner third clavicle and base is by T10 on posterior wall

Aging lungs

lose elasticity, respiratory muscle strength decreases, bones lose density

dyspnea

decreased level of consciousness, respirations greater 30 per minute, oxygen sat less than 90%, intercostal retractions, accessory muscle use

Common Respiratory Symptoms

chest pain, dyspnea, cough, orthopnea, paroxysmal nocturnal dyspnea, sputum, audible wheezing, change in functional ability

Initial Respiratory Survey

evaluating patient position, pursed lips, nasal flaring, level of consciousness, skin color, respiratory movement and rate, oxygen sat, accessory muscle use, intercostal rxns

Abnormal breathing patterns

tachypnea, hyperventilation, bradypnea, hypoventilation, cheyne-stokes respiration, biot breathing, agonal breathing, apnea

Objective Respiratory Assessment

inspection, chest expansion, palpation, tactile fermitus, percussion, diaphragmatic excursion, auscultation

Breathing sounds

vesicular, bronchail, bronchovesicular

Adventitious Lung Sounds

crackles, wheezes, rhonci, pleural friction rub, stridor

Auscultate transmitted voices

Bronchophony, egophony, whispered pectoriloquy

Common Respiratory Nursing Diagnoses

impaired gas exchange, ineffective airway clearance, activity intolerance, ineffective breathing pattern

CV System

Double pump with pulmonary and systemic circulation

Cardiac Cycle

rhythmic movements of systole and diastole

S1

closure of mitral and tricuspid valves signals beginning of systole

S2

closure of aortic and pulmonic valves, beginning of diastole and end of systole

Risk factors for cardiovascular disease

age, family history, male, high bp, high blood cholesterol level, smoking, diabetes mellitus, overweight, decreased activity, high fat diet, excessive alcohol intake, elevated C-reactive protein, elevated BNP

CVD Symptoms

chest pain, dyspnea, orthopnea, cough, diaphoresis, fatigue, edema, nocturia

PMI

largest part of heart felt

Cardiac auscultation locations

percordium--aortic, pulmonic, tricuspid, mitral